1215004874 NPI number — GRAYSLAKE FAMILY HEALTH CENTER SC

Table of content: (NPI 1215004874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215004874 NPI number — GRAYSLAKE FAMILY HEALTH CENTER SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAYSLAKE FAMILY HEALTH CENTER SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215004874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1475 E BELVIDERE RD
Provider Second Line Business Mailing Address:
SUITE 312
Provider Business Mailing Address City Name:
GRAYSLAKE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60030-2012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-584-5721
Provider Business Mailing Address Fax Number:
312-964-1468

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1475 E BELVIDERE RD
Provider Second Line Business Practice Location Address:
SUITE 312
Provider Business Practice Location Address City Name:
GRAYSLAKE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60030-2012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-845-7213
Provider Business Practice Location Address Fax Number:
312-694-0655
Provider Enumeration Date:
11/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOLLOWAY
Authorized Official First Name:
ALISON
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PHYSICIAN PRESIDENT
Authorized Official Telephone Number:
847-548-8430

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  036098167 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036098167 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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